More than half of older adults die within 1 year of initiating dialysis, far more than the 30% rate calculated by the US Renal Data System (USRDS) registry, according to a new study.

The USRDS omits those who die before an outpatient dialysis provider enters them into the registry, Melissa Wachterman, MD, MSc, MPH, of Veterans Affairs Boston Health Care System, and colleagues explained in a paper published in JAMA Internal Medicine. For a more realistic estimate, the investigators analyzed data from the nationally representative Health and Retirement Study of Medicare patients older than 65.5 years. Among 391 Medicare beneficiaries initiating dialysis, 17% were 85 years or older, 23% required assistance with activities of daily living, 68% had 4 or more comorbidities, and 73.1%  started dialysis in the hospital.

Results showed that 22.5%, 44.2%, and 54.5% of patients died within 30, 180, and 365 days of initiating dialysis, respectively. Within 1 year, 73% of older patients who required assistance with 1 or more daily activities, 71% of those aged 85 years or older, and 62% of inpatients initiating dialysis had died. Each of these patient groups had about twice the risk of 1-year mortality, Dr Wachterman’s team found. Older adults with 4 or more comorbidities had 1.5 times the risk of dying within a year.

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“These results provide a complement to data from the USRDS registry,” Dr Wachterman and colleagues wrote. “By more closely approximating real-world clinical situations in which it cannot be known whether patients will require chronic dialysis and whether they will survive long enough to enter the USRDS registry, these results may further support shared decision making regarding dialysis initiation.”

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Wachterman MW, O’Hare AM, Rahman OK, et al. One-year mortality after dialysis initiation among older adults. JAMA Intern Med. 2019. doi: 10.1001/jamainternmed.2019.0125